Background Human Brucellosis is a zoonosis and endemic in Mediterranean area. Localised osteoarticular manifestations of brucellosis include spondylitis, sacroiliitis, mono/oligoarthritis and bursitis. Coexistence of lumbar intervertebral disc herniation in spondylitis cases which do not have fever and constitutional symptoms, however, makes the diagnosis challenging.
Objectives We describe a patient with brucella spondylitis accompanying L4–5 and L5-S1 herniated nucleus pulposus (HNP).
Methods A 50 year old woman admitted to our outpatient clinic with low back pain, radiating to the lateral aspect of the left thigh lasting for 3 weeks. She did not have any history of fever, chills and constitutional symptoms. On physical examination, she was afebrile and only had tenderness over the lumbosacral region. The neurological examination revealed hypoesthesia in the right lower extremity overlapping the L5 dermatome. Straight leg raising test was positive on the right side.
Results Laboratory values were as follows: erythrocyte sedimentation rate 16 mm/hr, leucocyte count 4600/mm3, haemoglobin 10.4 gr/dl, C-reactive protein 0.143 mg/dl. Hepatic and renal function tests were normal. Seroagglutination test for brucella was 1/640. Plain radiography of the lumbar region revealed L5 spondylolisthesis and narrowed disc space between L5-S1 vertebrae. Magnetic resonance imaging (MRI) disclaimed L5 spondylolisthesis, spondylolysis, L5-S1 discitis, L5-S1 HNP, bilateral foraminal stenosis and L4-L5 minimal posterior protrusion. Total body bone scan with Tc-99m sulfur colloid revealed increased uptake at the superior region of the sacrum. Oral treatment with doxycycline and rifampin was started. There was overt clinical improvement after combined antibiotic regimen for 6 weeks. After a symptom-free period of 7 weeks a relapse occurred. An oral regimen of rifampin and ofloxacin was started again. Following up with the antibiotic therapy and immobilisation with rigid lumbosacral brace, she had a dramatic reduction in low back pain and she had regressive findings of the lesion in the control MRI.
Conclusion In some areas where brucellosis is rarely seen, due to non-spesific clinical picture and low index of suspicion, disease can easily be misdiagnosed. Spinal brucellosis can be confused with disc herniation, leading to inappropriate treatment and increased morbidity. In endemic regions, coexistence with lumbar disc herniation, like in our patient, should always be in mind of the physician and clinically, diagnosing of herniation alone should not seem satisfactory all the time.
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